Pharmacist driven antibiotic redosing in the emergency department

STUDY OBJECTIVE

Determine whether an expanded emergency medicine (EM) pharmacist scope of practice reduces the frequency of major delays in subsequent antibiotic administration in patients boarded in the emergency department (ED).

METHODS

A pre-post, quasi-experimental study conducted from November 2019-March 2020 at a single-center tertiary academic medical center following the implementation of an expanded EM pharmacist scope of practice. Adult patients were included if they received an initial antibiotic dose in the ED and deemed to be high-risk. Subsequent antibiotic doses were reordered by EM pharmacists for up to 24-h after the initial order pending ED length of stay (LOS). The historical control group consisted of retrospective chart review of cases from the previous year.

RESULTS

The study identified that of the 181 participants enrolled, major delays in subsequent antibiotic administration occurred in 13% of the intervention group and 48% of the control group (p < 0.01). When compared to the control group, the intervention group had a significant decrease in the number of delays among antibiotics dosed at 6-h (39% vs 13%) and 8-h (60% vs 8%) intervals. For antibiotics dosed at 12-h intervals, no statistically significant difference was observed between the control and intervention groups respectively (19% vs 5%). A statistically significant lower incidence of in-hospital mortality was observed in the intervention group (3% vs 11%, p = 0.02). In the intervention group, 97% of patients received subsequent antibiotic doses while boarded in the ED, compared to 65% in the control group (<0.01).

CONCLUSION

Expanding EM pharmacist scope of practice was associated with a significant reduction in the frequency of major delays in subsequent antibiotic administration as well as a decreased incidence of hospital mortality.

Compassionate Use of Tocilizumab for Treatment of SARS-CoV-2 Pneumonia

BACKGROUND

Preliminary data from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia patients indicate that a cytokine storm may increase morbidity and mortality. Tocilizumab (anti-IL-6R) is approved by the Food and Drug Administration for treatment of cytokine storm associated with chimeric antigen receptor T-cell therapy. Here we examined compassionate use of tocilizumab in patients with SARS-CoV-2 pneumonia.

METHODS

We report on a single-center study of tocilizumab in hospitalized patients with SARS-CoV-2 pneumonia. All patients had confirmed SARS-CoV-2 pneumonia and oxygen saturations <90% on oxygen support with most intubated. We examined clinical and laboratory parameters including oxygen and vasopressor requirements, cytokine profiles, and C-reactive protein (CRP) levels pre- and post-tocilizumab treatment.

RESULTS

Twenty-seven SARS-CoV-2 pneumonia patients received one 400 mg dose of tocilizumab. Interleukin (IL)-6 was the predominant cytokine detected at tocilizumab treatment. Significant reductions in temperature and CRP were seen post-tocilizumab. However, 4 patients did not show rapid CRP declines, of whom 3 had poorer outcomes. Oxygen and vasopressor requirements diminished over the first week post-tocilizumab. Twenty-two patients required mechanical ventilation; at last follow-up, 16 were extubated. Adverse events and serious adverse events were minimal, but 2 deaths (7.4%) occurred that were felt unrelated to tocilizumab.

CONCLUSIONS

Compared to published reports on the morbidity and mortality associated with SARS-CoV-2, tocilizumab appears to offer benefits in reducing inflammation, oxygen requirements, vasopressor support, and mortality. The rationale for tocilizumab treatment is supported by detection of IL-6 in pathogenic levels in all patients. Additional doses of tocilizumab may be needed for those showing slow declines in CRP. Proof of efficacy awaits randomized, placebo-controlled clinical trials.

259. A Prospective, Stewardship-Driven IV to PO Conversion in Uncomplicated Bacteremia

Background

Recent data has shown a transition to oral (PO) antibiotics (ABX) for definitive treatment of uncomplicated bacteremia has similar efficacy compared to continuation of intravenous (IV) ABX, and reduces hospital length of stay (LOS). The purpose of this study was to evaluate the safety and efficacy of an antimicrobial stewardship pharmacist-driven, IV to PO ABX transition in clinically stable patients with uncomplicated bacteremia, and to determine the impact on hospital LOS.

Methods

This was a prospective, interventional study with concurrent controls, conducted at Cedars-Sinai Medical Center between November 2019 and April 2020. For patient recruitment, a report of all positive inpatient blood cultures was reviewed daily. For patients meeting study criteria, the treating provider was contacted to recommend an IV to PO ABX transition. The treating provider was responsible for making the final determination on ABX therapy. Patients continuing IV ABX served as the comparator group to those transitioning to PO.

The primary outcome of interest was a composite of: 30-day, all-cause mortality, 30-day readmission due to infectious- or ABX-related complications, or 30-day recurrent infection with the same organism recovered. The second outcome of interest was overall hospital LOS and hospital LOS after the definitive ABX regimen was established.

Results

A total of 117 patients were evaluated; 69 patients met criteria for inclusion in the study (46 PO ABX / 23 IV ABX). Overall, baseline characteristics were similar between the groups. No difference was observed in the 30-day composite outcome (1 in each group), but the median, overall hospital LOS was three days shorter in the PO group. Furthermore, hospital LOS after the definitive ABX regimen was established was four days shorter in the PO group. Based on the differences in hospital LOS observed, the intervention was estimated to have resulted in approximately $819,200 cost-avoidance during the study period.

Conclusion

Similar to prior studies, our findings support the safety and effectiveness of an IV to PO ABX transition in clinically stable patients with uncomplicated bacteremia. Antimicrobial stewardship pharmacists can be leveraged to facilitate such a transition.

Disclosures

All Authors: No reported disclosures

Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States

Data on the detailed clinical progression of COVID-19 in conjunction with epidemiological and virological characteristics are limited. In this case series, we describe the first 12 US patients confirmed to have COVID-19 from 20 January to 5 February 2020, including 4 patients described previously^1-3. Respiratory, stool, serum and urine specimens were submitted for SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) testing, viral culture and whole genome sequencing. Median age was 53 years (range: 21-68); 8 patients were male. Common symptoms at illness onset were cough (n = 8) and fever (n = 7). Patients had mild to moderately severe illness; seven were hospitalized and demonstrated clinical or laboratory signs of worsening during the second week of illness. No patients required mechanical ventilation and all recovered. All had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2-3 weeks after illness onset. Lowest real-time PCR with reverse transcription cycle threshold values in the upper respiratory tract were often detected in the first week and SARS-CoV-2 was cultured from early respiratory specimens. These data provide insight into the natural history of SARS-CoV-2. Although infectiousness is unclear, highest viral RNA levels were identified in the first week of illness. Clinicians should anticipate that some patients may worsen in the second week of illness.

Cefotetan-Induced Hemolytic Anemia: Case Series and Review

PURPOSE

To raise awareness of cefotetan-induced hemolytic anemia, a known rare but serious side effect that occurred in 5 patients at our medical center.

SUMMARY

Five cases of cefotetan-induced hemolytic anemia, which presented over the period of a single year at our center, are described. In each case, hemolytic anemia was confirmed by testing for the presence of anti-cefotetan antibodies. Each case occurred approximately 1 to 2 weeks following exposure to the drug. All five patients survived. A brief review of drug-induced immune hemolytic anemia (DIIHA) is also discussed.

CONCLUSION

DIIHA may be difficult to distinguish from other causes of hemolytic anemia, but should be included in the differential in patients exposed to medications associated with DIIHA. Once suspected, antibody testing should be performed, and once diagnosed, further exposure should be avoided.

Effectiveness and response predictors of omalizumab in a severe allergic asthma population with a high prevalence of comorbidities: the Australian Xolair Registry

BACKGROUND

Severe asthma is a high impact disease. Omalizumab targets the allergic inflammatory pathway; however, effectiveness data in a population with significant comorbidities are limited.

AIMS

To describe severe allergic asthma, omalizumab treatment outcomes and predictors of response among the Australian Xolair Registry participants.

METHODS

A web-based post-marketing surveillance registry was established to characterise the use, effectiveness and adverse effects of omalizumab (Xolair) for severe allergic asthma.

RESULTS

Participants (n = 192) (mean age 51 years, 118 female) with severe allergic asthma from 21 clinics in Australia were assessed, and 180 received omalizumab therapy. They had poor asthma control (Asthma Control Questionnaire, ACQ-5, mean score 3.56) and significant quality of life impairment (Asthma-related Quality of Life Questionnaire score 3.57), and 52% were using daily oral corticosteroid (OCS). Overall, 95% had one or more comorbidities (rhinitis 48%, obesity 45%, cardiovascular disease 23%). The omalizumab responder rate, assessed by an improvement of at least 0.5 in ACQ-5, was high at 83%. OCS use was significantly reduced. The response in participants with comorbid obesity and cardiovascular disease was similar to those without these conditions. Baseline ACQ-5 ≥ 2.0 (P = 0.002) and older age (P = 0.05) predicted the magnitude of change in ACQ-5 in response to omalizumab. Drug-related adverse events included anaphylactoid reactions (n = 4), headache (n = 2) and chest pains (n = 1).

CONCLUSION

Australian patients with severe allergic asthma report a high disease burden and have extensive comorbidity. Symptomatic response to omalizumab was high despite significant comorbid disease. Omalizumab is an effective targeted therapy for severe allergic asthma with comorbidity in a real-life setting.

Building operational research capacity in the Pacific

Operational research (OR) in public health aims to investigate strategies, interventions, tools or knowledge that can enhance the quality, coverage, effectiveness or performance of health systems. Attention has recently been drawn to the lack of OR capacity in public health programmes throughout the Pacific Islands, despite considerable investment in implementation. This lack of ongoing and critical reflection may prevent health programme staff from understanding why programme objectives are not being fully achieved, and hinder long-term gains in public health. The International Union Against Tuberculosis and Lung Disease (The Union) has been collaborating with Pacific agencies to conduct OR courses based on the training model developed by The Union and Médecins Sans Frontières Brussels-Luxembourg in 2009. The first of these commenced in 2011 in collaboration with the Fiji National University, the Fiji Ministry of Health, the World Health Organization and other partners. The Union and the Secretariat of the Pacific Community organised a second course for participants from other Pacific Island countries and territories in 2012, and an additional course for Fijian participants commenced in 2013. Twelve participants enrolled in each of the three courses. Of the two courses completed by end 2013, 18 of 24 participants completed their OR and submitted papers by the course deadline, and 17 papers have been published to date. This article describes the context, process and outputs of the Pacific courses, as well as innovations, adaptations and challenges.

Summarising published results from spirometric surveys of COPD: the problem of inconsistent definitions

SETTING

The use of different spirometric definitions for chronic obstructive pulmonary disease (COPD) has made an informative review of the available prevalence surveys impossible.

OBJECTIVE

To derive adjustment factors that allow the comparison of studies using different spirometric criteria.

METHODS

Pre- and post-bronchodilator one-second forced expiratory volume (FEV1) and forced vital capacity (FVC) values were taken from the Burden of Obstructive Lung Disease (BOLD) survey in 16 centres. Using a post-bronchodilator FEV1/FVC ratio less than the lower limit of normal (LLN) as our reference prevalence, we calculated simple multiplicative adjustments to transform other reported prevalence estimates to reference values. These adjustments were then tested on independent data sets from six further BOLD centres and five centres from the PLATINO study, a Latin American survey on obstructive lung disease.

RESULTS

Prevalence estimates based on pre-bronchodilator fixed-ratio measurements were 5-25% higher than reference values, and were strongly positively biased with age and prevalence level. Applying simple adjustments provided prevalence estimates that were almost unbiased and within 5% of the reference values.

CONCLUSIONS

Using the BOLD data, we have been able to estimate COPD prevalences based on post-bronchodilator FEV1/FVC < LLN by adjusting estimates based on other common definitions, enabling more meaningful comparisons of published findings.

Liquid versus solid energy intake in relation to body composition among Australian children

BACKGROUND

The debate about whether energy consumed in liquid form is more obesogenic than energy consumed in solid form remains equivocal. We aimed to evaluate the effects of liquid versus solid energy intake and different beverage types on changes in childhood adiposity.

METHODS

Our analyses included 8-year-old Australian children (n = 158) participating in the Childhood Asthma Prevention Study. Dietary information was collected using three 24-h recalls at age 9 years. Multivariate linear regression was used to evaluate the effects of liquid versus solid energy intake and different beverage types on changes in body mass index (BMI) Z-score from ages 8 to 11.5 years (△BMIz(8-11.5y)) and percentage body fat (%BF) at age 11.5 years (%BF(11.5y)). Substitution models were used to evaluate the effects of substituting other beverage types for sugar-sweetened beverages (SSB).

RESULTS

Liquid energy intake (1 MJ day(-1)) was more closely associated with both △BMIz(8-11.5y) (β = 0.23, P = 0.02) and %BF(11.5y) (β = 2.31%, P = 0.01) than solid energy intake (△BMIz(8-11.5y): β = 0.12, P = 0.01 and %BF(11.5y): β = 0.80%, P = 0.07). SSB consumption (100 g day(-1)) was directly associated with △BMIz(8-11.5y) (β = 0.08, P = 0.02) and %BF(11.5y) (β = 0.92%, P = 0.004),whereas diet drinks (100 g day(-1) ) were inversely associated with △BMIz(8-11.5y) (β = 0.18, P = 0.02). Substitution of 100 g of SSB by 100 g of water or diet drink, but not other beverages, was inversely associated with both △BMIz(8-11.5y) and %BF(11.5y) (P < 0.01).

CONCLUSIONS

Our findings indicate that liquid energy is more obesogenic than solid energy. In particular, SSB, but not other beverage types, are a significant predictor of childhood adiposity and replacing SSB with water can have long-term beneficial effects on childhood adiposity.

Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy

BACKGROUND

This study reports the short- and long-term results for a prospective rectal cancer management program using laparoscopic radical transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) after neoadjuvant therapy.

METHODS

A prospective database included 102 rectal cancer patients treated with laparoscopic TATA from 1998 to 2008. Patients with distant metastasis at presentation, patients with a tumor more than 3 cm from the anorectal ring, and patients not undergoing neoadjuvant therapy were excluded, leaving 79 patients (54 men and 25 women) with a mean age of 59.2 years (range, 22-85 years) for this study. 13 patients completed neoadjuvant therapy before the original evaluation, and they are excluded from the report of initial clinical assessment. Before treatment, 50 patients were staged as T3 and 16 patients as T2. The mean level in the rectum superior to the anorectal ring was 1.2 cm (range, -0.5 to 3 cm). In terms of fixity, 31 of the tumors were mobile, 27 were tethered, and 8 showed early fixation. Ulceration was absent in 8 cases, minimal in 12 cases, superficial in 7 cases, moderate in 22 cases, and deep in 17 cases. The mean pretreatment tumor size tumor was 4.8 cm (range, 1.5-12 cm). The median external beam radiation was 5,400 cGy (range, 3,000-8,040 cGy), and 77 patients underwent chemotherapy.

RESULTS

The mean follow-up period was 34.2 months (range, 1.9-113.9 months). There were no perioperative mortalities. The conversion rate was 2.5%, and the mean largest incision length was 4.3 cm (range, 1.2-21 cm). For 84% of the patients, the incision was less than 6.0 cm, and 46% of the patients had no abdominal incision for delivery of the specimen. The mean estimated blood loss was 367 ml (range, 75-2,200 ml). All the patients had a temporary diverting stoma. The major morbidity rate was 11%, and the minor morbidity rate was 19%. The major complications included four full-thickness rectal prolapses with repair, one ischemic neorectum with successful reanastomosis, two bowel obstructions, and two failed anastomoses requiring stoma. The ypT stages included 22 complete responses, 12 cases of ypT1, 22 cases of ypT2, 23 cases of ypT3; 65 cases of ypN0, and 14 cases of ypN + (T3 = 7, T2 = 4, T1 = 3). The local recurrence rate was 2.5% (2/79), and the distant metastases rate was 10.1% (8/79). The KM5YAS rate was 97%. Overall, 90% of the patients lived without a stoma. Neorectal loss was due to positive margins or recurrence and was followed by abdominoperineal resection in three cases and ischemia in two cases. The condition of two patients was not reversed due to comorbidities, and one patient had a stoma secondary to bowel obstruction.

CONCLUSION

The study results indicate excellent local recurrence (2.7%) and 5-year survival rates without the need for permanent colostomy in patients with cancers in the distal one-third of the rectum. Laparoscopic total mesorectal excision (TME) with the TATA approach is safe and can be performed laparoscopically. Multi-institutional studies are required to establish the reproducibility of this promising approach.

Seasonal trends in house dust mite allergen in children's beds over a 7-year period

BACKGROUND

House dust mite (HDM) allergy is closely linked to the expression of asthma and other allergic diseases. Understanding factors influencing variation in allergen may help in controlling allergic disease. The objective of this study was to investigate the effects of seasonal changes in climate, type of bed used in very early childhood and anti-mite interventions on HDM allergen concentration.

METHODS

Participants were enrolled in a randomized-controlled trial of HDM avoidance. Der p 1 was measured in dust samples from children's beds on 13 occasions, from birth to age 5 years, between 1997 and 2004. Bed types were categorized as bassinette, cot or bed. The effects of study month, type of bed and intervention group on HDM allergen concentration were estimated by multiple linear regression. The relation between climatic variables and HDM allergen concentration was investigated using a polynomial distributed lag model.

RESULTS

House dust mite allergen concentrations were initially low in cots and bassinettes in 1997/1998, peaked in bassinettes and beds between 1999 and 2001 and then slowly declined during the period 2002/2004. Seasonal fluctuations occurred with minima in summer and two- to threefold higher maxima during late autumn. Allergen peaks were correlated with relative humidity peaks 2 months previously. Seasonal changes in allergen were not affected by the HDM avoidance intervention.

CONCLUSIONS

House dust mite allergen concentrations in Sydney beds fluctuate approximately two- to threefold on an annual cycle, partly determined by relative humidity, with peaks in late autumn and minima in summer. Fluctuations of this magnitude might be sufficient to influence asthma symptoms.

Twenty-nine year study on circadian distribution of urinary zinc levels of same male subjects

OBJECTIVES

To examine the circadian distribution and total 24h levels of urinary zinc (Zn) in same male subjects over an extended period of time in order to ascertain their relationship with aging.

MATERIALS AND METHODS

Eight young army volunteers served as subjects over a period of 29 years: 1969, 1979, 1988, 1998. By 1979 three of them became latent diabetics. Complete physical examination, anthropometric measurements and same procedural protocol was followed in each study. Samples were collected over 3 hour periods for 24 hours in the middle of each month of May. Urine aliquots were analyzed for creatinine, using conventional laboratory procedure. Zn was analyzed using Atomic Absorption Spectrophotometry in 1969, and 1979 and by Inductively Coupled Plasma, in 1988 and 1998.

RESULTS

Over the course of 29 years the circadian distribution of Zn was altered by decrease in amplitude in Zn levels, while the 24h concentrations of Zn decreased progressively with increasing age in healthy and diabetic subjects: Healthy; 966+/-130 microg at age of 29; 666+/-14 microg at 39; 511+/-80 microg at 48; and 555+/-71 microg at age of 58y; Diabetics exhibited similar trend; 1757+/-60 microg at age 28; 1253+/-40 microg at age 38, 1132+/-31 microg at 47, and 1025+/-11 microg at the age of 57. Anthropometric measurements in each study period revealed significant increases in diabetic subjects for body weight, body surface area, BMI and significant decrease in body heights of both groups.

CONCLUSIONS

The daily excretion of urinary Zn over the 29 years period decreased by 42% in healthy and diabetic subjects. Although there appears to be a lack of a reliable index of intracellular Zn status to accurately monitor and control zinc deficiency in younger and older populations, the present data suggest that depletions of Zn are also evident in healthy aging subjects whose daily diet was not deficient in zinc.

Are the prevalence and treatment of asthma similar in elite athletes and the aged-matched non-athlete population?

The objective of this study was to determine the prevalence of asthma and use of asthma medications in elite athletes compared with an age-matched non-athlete population. Data were collected from the respiratory component of annual medical screening of 424 elite athletes from the Queensland Academy of Sport. Measures included the prevalence of current asthma and ever doctor-diagnosed asthma, and the prevalence of use of treatment for asthma including beta-agonists and inhaled corticosteroid medication. The prevalence of current asthma in athletes aged 18-29 years was 14% (95% CI, 9-19%), which did not differ significantly from the prevalence in the non-athlete control population (11%; 95% CI, 9-12%, P=0.3). Of athletes with current asthma, 27% were not taking any medications for asthma, and 25% were treated with short-acting beta-agonist medications alone and were not taking inhaled corticosteroids. These data indicate that the overall cumulative and period prevalence of asthma in Queensland athletes is similar to that in the general age-matched population. Athletes use beta-agonists with a frequency similar to the general population.

Communication of HIV viral load to guide sexual risk decisions with serodiscordant partners among San Francisco men who have sex with men

The objective of this study was to estimate frequency and correlates of discussing HIV viral load (VL) with serodiscordant sex partners to guide decisions about sexual activities among men who have sex with men (MSM). We conducted a cross-sectional survey of 573 San Francisco MSM. Among 507 who knew their HIV status, 397 (78%) were familiar with the term 'viral load', and half (n=199) had a serodiscordant partner in the prior year. These 199 respondents (n=130 [65%] HIV-positive; n=69 [35%] HIV-negative) were the focus of this analysis. A majority (n=111, 56%) discussed VL in the prior year with serodiscordant partners specifically to guide decisions about sexual risk behaviour. Discussion was more common among HIV-positive than HIV-negative participants (adjusted odds ratio [AOR], 3.5; 95% confidence interval [CI], 1.6-7.6), and African Americans compared to whites (AOR, 3.7; 95% CI, 1.5-9.5). HIV-negative men who discussed VL were more concerned about becoming infected, but also more willing to engage in risky behaviour with a partner whose VL is undetectable, than men not discussing VL. Some HIV-negative men may be discussing VL to engage in higher risk behaviour upon learning of an HIV-positive partner's undetectable VL. Interventions targeting MSM should explain that while risk of transmission is likely reduced with a low blood plasma VL, it is not necessarily eliminated.

Factors associated with use of HIV primary care among persons recently diagnosed with HIV: Examination of variables from the behavioural model of health-care utilization

The delay between testing positive for human immunodeficiency virus (HIV) and entering medical care can be better understood by identifying variables associated with use of HIV primary care among persons recently diagnosed with the virus. We report findings from 270 HIV-positive persons enrolled in the Antiretroviral Treatment Access Study (ARTAS). 74% had not seen an HIV care provider before enrollment; 26% had one prior visit only. Based on Andersen's behavioural model of health care utilization, several variables reflecting demographic, healthcare, illness, behavioural, and psychosocial dimensions were assessed and used to predict the likelihood that participants had seen an HIV care provider six months after enrollment. Overall, 69% had seen an HIV care provider by six months. In multivariate analysis, the likelihood of seeing a provider was significantly (p<.05) higher among men, Hispanics (vs. non-Hispanic Blacks), those with higher education, those who did not use injection drugs, those with three or more HIV-related symptoms, those with public health insurance (vs. no insurance), and those who received short-term case management (vs. passive referral). The findings support several conceptual categories of Andersen's behavioural model of health services utilization as applied to the use of HIV medical care among persons recently diagnosed with HIV.

Cost-effectiveness of current and optimal treatment for adult asthma

BACKGROUND

This article is part of a project to determine the cost-effectiveness of averting the burden of disease. We used population data to investigate the costs and benefits of allocating resources to optimal treatment for asthma in adults, using a burden of disease framework.

METHODS

We calculated the population burden of asthma in the absence of any treatment as years lived with disability (YLD), ignoring the years of life lost. We then estimated the proportion of burden averted with current interventions, the proportion that could be averted with optimally implemented current evidence-based guidelines and the direct treatment cost-effectiveness ratio in dollarA per YLD averted for both current and optimal treatment.

RESULTS

The direct treatment cost of current treatment of adult asthma in Australia was dollar A452 million and averted 25% of the burden with a cost-effectiveness ratio of dollar A14 000/YLD averted. Optimal treatment and optimal compliance would cost dollar A627 million and avert 69% of the burden with a cost-effectiveness ratio of dollar A7000/YLD averted.

CONCLUSION

Implementation of optimal treatment for asthma is affordable, will be more cost-effective and will significantly decrease disability.

Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men

OBJECTIVES

There is evidence that methamphetamine and sildenafil (Viagra) use are associated with sexual risk behaviour among men who have sex with men (MSM). We investigated the association of methamphetamine, sildenafil, and other substance use with unprotected receptive and insertive anal sex among MSM by conducting an encounter specific analysis.

METHODS

Data were from a cross sectional, community based survey of MSM in San Francisco regarding behaviour during their most recent anal sex encounter. Mulitvariate regression analysed independent associations of specific substance use and demographic variables with unprotected anal sex behaviours.

RESULTS

The sample (n = 388) was diverse in race/ethnicity, age, income, education, HIV status, and homosexual/bisexual identification. More than half (53%) reported unprotected anal sex, including insertive (29%) and receptive (37%) during their most recent anal sex encounter; 12% reported unprotected insertive and 17% reported unprotected receptive anal sex with an HIV discordant or unknown partner. Methamphetamine was used by 15% and sildenafil was used by 6% of the men before or during the encounter; 2% used both drugs. In multivariate analysis controlling for demographic factors and other substance use, methamphetamine use was associated with unprotected receptive (odds ratio (OR), 2.03; 95% confidence interval (CI), 1.09 to 3.76) and sildenafil use was associated with unprotected insertive (OR, 6.51; CI, 2.46 to 17.24) anal sex. Effects were stronger with HIV discordant or unknown sex partners specifically.

CONCLUSION

Encounter specific associations of methamphetamine and sildenafil use with unprotected receptive and insertive anal sex, respectively, indicate the importance of assessment specificity and tailoring risk reduction efforts to address certain drugs and sexual behavioural roles among MSM.

Increased motor drive and sleep loss in mice lacking Kv3-type potassium channels

The voltage-gated potassium channels Kv3.1 and Kv3.3 are widely expressed in the brain, including areas implicated in the control of motor activity and in areas thought to regulate arousal states. Although Kv3.1 and Kv3.3-single mutants show some physiological changes, previous studies revealed relatively subtle behavioral alterations suggesting that Kv3.1 and Kv3.3 channel subunits may be encoded by a pair of redundant genes. In agreement with this hypothesis, Kv3.1/Kv3.3-deficient mice display a 'strong' mutant phenotype that includes motor dysfunction (ataxia, myoclonus, tremor) and hyperactivity when exposed to a novel environment. In this paper we report that Kv3.1/Kv3.3-deficient mice are also constitutively hyperactive. Compared to wildtype mice, double mutants display 'restlessness' that is particularly prominent during the light period, when mice are normally at rest, characterized by more than a doubling of ambulatory and stereotypic activity, and accompanied by a 40% sleep reduction. When we reinvestigated both single mutants, we observed constitutive increases of ambulatory and stereotypic activity in conjunction with sleep loss in Kv3.1-single mutants but not in Kv3.3-single mutants. These findings indicate that the absence of Kv3.1-channel subunits is primarily responsible for the increased motor drive and the reduction in sleep time.

Serostatus disclosure, sexual communication and safer sex in HIV-positive men

This study assessed HIV-positive men's sexual behaviours with partners at risk for infection, and examined the extent to which safer sex was associated with interpersonal communication variables, namely, (1). disclosure of one's seropositive status and (2). specific communication with partners about safer-sex practices. A total of 105 HIV-positive men (43% homosexual, 38% bisexual, 19% heterosexual), randomly sampled at an HIV outpatient clinic in Los Angeles, completed a behavioural questionnaire assessing events in their most recent sexual encounter with an HIV-negative or unknown serostatus partner. Results indicated that men who disclosed their seropositive status and explicitly discussed the topic of safer sex with their at-risk partners had a significantly higher prevalence of protected anal or vaginal intercourse than did men who disclosed only. The findings suggest that post-test counselling regarding the importance of disclosing one's seropositive status to sex partners should be augmented by behavioural interventions that enhance seropositive persons' skills in communicating explicitly with partners about safer sex to help reduce transmission of HIV.

Predictors of high house dust mite allergen concentrations in residential homes in Sydney

BACKGROUND

In parts of coastal Australia, house dust mite allergen concentrations in homes are often very high with at least 80% of homes in Sydney exceeding concentrations of 10 microg of allergen per gram of fine dust. In this study, we report the relation between characteristics of the home environment and house dust mite allergen concentrations at three sites in Sydney homes.

METHODS

A total of 616 families were recruited as part of the Childhood Asthma Prevention Study (CAPS). Information about the home environment and structural aspects of the home was collected using a questionnaire. Samples of dust were collected from the parents' bed, the bedroom floor and the living room floor and assayed for Der p 1.

RESULTS

A total of 68% of participants' beds, 65% of bedroom floors and 56% of living room floors had Der p 1 concentrations above 10 microg/g, with the highest concentrations of allergen in the bed. The most significant predictor of high Der p 1 concentrations in the bed and floors was the age of the home. We also found that beds with mattresses over two years old and with woollen or synthetic blankets or synthetic quilts had higher Der p 1 concentrations. Carpeted floors had higher Der p 1 concentrations than hard floors.

CONCLUSION

The finding that high Der p 1 allergen concentrations in homes with carpets and older mattresses indicates that control strategies directed at these sources are likely to be effective in reducing exposure. Alternatives such as the use of house dust mite impermeable mattress encasings on older mattresses may also be effective in reducing exposure.

Are negative affective states associated with HIV sexual risk behaviors? A meta-analytic review

This meta-analytic review examined whether negative affective states (depressive symptomatology, anxiety, anger) are associated with sexual behaviors that place people at risk for contracting or transmitting HIV. The results from 34 study samples were included in the analysis. Contrary to popular belief, the findings as a whole provide little evidence that negative affect is associated with increased sexual risk behavior. The average weighted correlation for the overall association was .05. The effect size was nonsignificantly higher for anger (r = .10) than for depressive symptoms (r = .04) or anxiety (r = .03). The variability of effect sizes was not accounted for by type of sexual risk measure, subject population, or methodological aspects of the studies. Conceptual and methodological limitations of the literature are identified and directions for future research are discussed.

Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison

CONTEXT

HIV risk behavior among urban gay/bisexual men has recently increased. High-risk sexual activity and drug use may be particularly high during circuit party (CP) weekends, during which gay/bisexual men congregate for social activities and dancing.

OBJECTIVES

To compare prevalence of risk behaviors during CP weekends with those during non-CP weekends.

DESIGN

Cross-sectional study.

PARTICIPANTS

295 gay/bisexual men from the San Francisco Bay Area.

MAIN OUTCOME MEASURES

Drug use and sexual risk behavior during a San Francisco CP weekend, a CP weekend held in another geographic area (distant weekends), and two non-CP weekends.

RESULTS

During their most recent distant CP weekend, 80% of participants used methylenedioxymethamphetamine (ecstasy), 66% ketamine, 43% crystal methamphetamines, 29% gamma-hydroxybutyrate or gamma-butyrolactone (GHB/GBL), 14% sildenafil (Viagra), and 12% amyl nitrites (poppers); 53% used four or more drugs. Drug use prevalence was greater during CP than non-CP weekends ( p <.001). Unprotected anal sex with partners of unknown or opposite HIV serostatus was most prevalent during distant CP weekends, reported by 21% of HIV-positive and 9% of HIV-negative participants. In multivariate analysis, predictors of unprotected anal sex with opposite or unknown HIV serostatus partners included being HIV-positive (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4-7.5), and weekend use of crystal methamphetamines (OR 2.4; 95% CI, 1.1-4.9), sildenafil (OR, 3.8; 95% CI, 2.0-7.3), and amyl nitrites (OR, 2.2; 95% CI, 1.3-4.0).

CONCLUSIONS

Prevalence of high-risk activity during these weekends suggests significant potential for HIV transmission in this population. Public health programs in communities hosting CPs should aim to reduce rates of drug use and sexual risk behavior among CP participants, especially HIV-positive men.

Parental smoking and respiratory tract infections in children

The adverse health consequences of exposing children to tobacco smoke have been well documented. Re-calculation of the data available from cohort and cross-sectional studies worldwide shows that between 500-2500 excess hospitalisations and between 1000 to 5000 excess diagnoses per 100 000 young children as result from respiratory infections can be directly attributed to parental smoking. Results of published meta-analyses support these figures, which are probably under-estimated because of the effects of non-differential misclassification bias. These excess infections are a source of preventable morbidity and have a high cost to the community. They also have important long-term consequences because children who have respiratory infections in early life are at an increased risk of developing asthma in later childhood. More effective strategies that prevent smoking in young people before they become parents have the potential to lead to reductions in these high rates of unnecessary morbidity in the next generation of children.

Use of V4R in patients who sustain blunt chest trauma

OBJECTIVE

In blunt chest trauma, the right ventricle is more vulnerable than the left. The purpose of this study was to determine whether recording V4R in patients with blunt chest trauma would provide additional useful information to that already obtained from the standard 12-lead electrocardiogram (ECG).

METHODS

Forty-five patients with blunt chest trauma and 40 unmatched control subjects without blunt chest trauma had standard 12-lead ECG and right precordial leads recorded. The ECGs were read blindly by three physicians.

RESULTS

Patients with chest trauma were distinguishable from controls on the basis of the left-sided ECGs (odds ratio, 2.9; 95% confidence interval, 1.71-4.90). This was not the case using V4R (odds ratio, 1.23; 95% confidence interval, 0.59-2.0).

CONCLUSION

Patients with a significant mechanism and physical findings of blunt chest trauma were more likely than controls to have an abnormal ECG. They were not more likely to have abnormalities in V4R. We recommend that a 12-lead ECG, but not V4R, be routinely obtained on these patients.